National Nurses United

5/27/08 12:35 PM Page 12 O n rare occasions, the media highlights a story about the high school football player who had to relearn how to speak after getting knocked unconscious in a game, or the woman who couldn't remember her husband and three kids after suffering a blow to the head in a car accident. But, in fact, traumatic brain injury is the most common cause of death for U.S. adults under the age of 45—deadlier than AIDS, multiple sclerosis, spinal cord injury, and breast cancer combined. It strikes down 1.6 million Americans a year. And adding to that 1.6 million figure are two ongoing wars whose signature injury is the blast-induced head wound. A February 2008 study by the Government Accountability Office found that "traumatic brain injury has emerged as the leading injury among U.S. forces serving in Afghanistan and Iraq." According to a Walter Reed Army Medical Center study, "closed brain injuries"—injuries with no visible marks—outnumber "penetrating brain injuries" seven to one. Other researchers put the ratio much higher. Yet traumatic brain injury, simply called TBI by those in the field, is a "silent epidemic," according to David Hovda, director of the Brain Injury Research Center at the University of California at Los Angeles. While TBI may be a quiet wound, the consequences for victims, family, friends, and coworkers can be catastrophic. "We are looking at a very frightening situation," said Dr. Judith Landau, psychiatrist and president of Linking Human Systems in Boulder, Colo., who works with vets and their families. T here's a lot more that researchers don't know about TBI than they do. For starters, it's hard to spot. "Our scans show nothing," said Dr. Michael Weiner, professor of medicine, radiology, psychiatry, and neurology at the University of California at San Francisco and director of the Center for Imaging of Neurodegenerative Disease at the Veterans Administration Medical Center. TBI is a slippery beast, or "murky" as Weiner puts it. It can cause symptoms ranging from depression and uncontrollable rages, to irritable bowels and emotional disengagement. It can suddenly appear long after the incident that caused it, and it is difficult and complex to treat. While there is general agreement in medicine about what causes TBI in impact injuries like an auto accident or a sports concussion, there is no such agreement when it comes to how massive explosions of roadside bombs affect the brain. Most researchers assume the damage comes from a violent shaking of the head. "These brains are rattled like a yolk in an egg," Jessica Martinez, an occupational therapist at Scripps Memorial Hospital in Encinitas, Calif., told the Los Angeles Times. However, P. Stephen Macedo, a doctor formerly with the Veterans Administration, told the Toronto Star, that when the force of an explosion "moves through the brain, it seems to cause little gas bubbles to form. When they pop, it leaves a cavity. So you are littering people's brains with these little holes." The same story reported that U.S. physician Susan Okie thinks the combination of a blast wave followed by a sudden drop in pressure is the culprit. Psychiatrist Evan Kanter of the University of Washington argues that explosions disconnect the amygdala, or emotional part of the brain, from the frontal lobes, which control planning and decision-making. 12 REGISTERED NURSE And Dr. Ibolja Cernak of Johns Hopkins postulates that blast waves generate powerful vibrations of major blood vessels in the chest and abdomen, which transfer that energy to areas deep in the brain, such as the hippocampus. Cernak says the damage eventually leads to premature aging of the brain. A Canadian study indicates that a blow powerful enough to cause unconsciousness causes a loss of brain tissue. "There is more damage and it is more widespread that we had expected," Brian Levine of the University of Toronto's Rotman Research Institute told the Toronto Star. Levine says the cell loss appears to be in the brain's white matter, which is essential for communication. Even a small loss in this region of the brain "will have a quite large effect on behavior" he said. H owever it's caused, the constellation of symptoms that TBI induce include short-term memory loss; stomach, chest, back, and head pain; dizziness; racing pulse; constipation; diarrhea; sexual dysfunction; insomnia; inability to concentrate; damage to hearing and vision; personality changes; and Post-Traumatic Stress Disorder (PTSD). Indeed, part of the problem in identifying TBI is that its symptoms are so similar to PTSD, another common illness of soldiers. A recent study of veterans returning from Iraq and Afghanistan found that the severity of those symptoms was greatly affected by the severity of the incident that caused the TBI. It depended on whether the victim was knocked unconsciousness, or was simply dazed and confused by the blast, in what is called an "altered state." A U.S. military study notes, "Injuries associated with the loss of consciousness carried a much greater risk of health problems than did injuries associated with altered mental states." The Pentagon says about 20,000 GIs have returned with TBI, but most experts say the figure is much higher. U.S. Rep. Bill Pascrell, founder of the Congressional Brain Injury Task Force, says the figure could be as high as 150,000. In fact, the number of potential TBI sufferers is almost twice what Pascrell estimated. According to an April 2008 Rand Corporation study, 320,000 service members may be suffering from TBI. TBI itself is hardly new. Some 5.3 million people in the country are currently hospitalized or in residential facilities because of it. And its consequences constitute some of our most challenging social problems. For instance, researchers have found a relationship between TBI W W W. C A L N U R S E S . O R G M AY 2 0 0 8 AP PHOTO/JEFF CHIU; PREVIOUS PAGE: AP PHOTO/THE NEWS TRIBUNE, DEAN J. KOEPFLER TBI:2

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